Some pregnant women are being denied a routine treatment to protect their unborn child, say investigators.
A simple injection can prevent a life-threatening condition known as rhesus disease, which occurs if the mother and her baby have incompatible blood groups.
All pregnant women should be screened and any found to have rhesus-negative blood should be offered the anti-D jab.
Over a period of 15 years from 1996 to 2011 there were 1,211 errors where women who should have received immediate treatment with the anti-D injection did not.
- Also known as haemolytic disease of the foetus and newborn (HDFN)
- Happens when the mother has rhesus-negative blood (RhD-negative) and the baby in her womb has rhesus-positive blood (RhD-positive)
- Because these two blood groups are incompatible, the mother’s immune system sees the baby as “alien” and switches to “destroy” mode
- Women who are RhD-negative should receive the anti-D jab to stop them making antibodies that could attack the baby
- All pregnant women should be screened to check if they are RhD-negative
In half of these cases, the woman either did not receive the treatment at all or received it late – mostly because the nurse, midwife or doctor on duty at the time failed to follow basic protocols.
Laboratory errors accounted for just over a quarter of the cases.
In a fifth of cases, the anti-D was given entirely inappropriately – either mistakenly to the wrong mother or to a woman who did not need it.
In nine cases, babies suffered the full-blown effects of the disease. One died and three needed blood transfusions.
The study authors from the University of Manchester are concerned that anti-D errors are still too common despite clear treatment guidelines.
Lead researcher Dr Paula Bolton-Maggs said: “Our findings show that over the 15 year reporting period the same mistakes were being made repeatedly by clinical and laboratory staff.
“These are clinically significant problems that require active attention at a national and local level as reported errors could be avoided by putting in place appropriate checks.”
“The RCM expects each maternity unit to have systems in place to ensure that all women requiring the anti-D prophylaxis injection receive it regardless of their length of postnatal stay, especially where they live outside the unit’s catchment area.
“This is especially important given the increase in births and pressure on maternity services.
“We need more midwives and more midwifery visits in the community so they can administer anti-D at home under the agreed time limits and spend time with women after they have given birth.”